Discussion about transgender people is back on the front page since President Trump tweeted his wish, and then ordered the Defense Department, to ban the enlisting of transgender persons and to ban transgender soldiersfrom continuing to serve in our armed forces. The ACLU notes that there are currently about 8000 transgender U.S. soldiers.

The appearance of your genitals at birth, if anatomically correct, tells everyone in the delivery room what you are; “sexual anatomy”. “It’s a boy, or it’s a girl” are the first three words an infant “hears”. In the first decade of life we begin to think of ourself as a boy or as a girl; “gender identification”. In our second decade, as we approach and go through puberty, we begin to realize that we are attracted to boys or girls, or both; “sexual orientation“. These three terms are often confused and intermixed in our discussion. which can make rational, unemotional consideration of new policy, laws, and societal changes very difficult.

When do children begin to identify themselves as a boy or a girl? (1)Studies show that it can be as early as third grade. (7-9 yo.) By then, most children associate themselves with one or the other sexes and understand that it is permanent; “girls grow up to be women and boys grow up to be men.”

What about “cross-gender” play which is very common at young ages?By age 2 years all children know sex stereotypes (“women are associated with lipstick”,”boys don’t wear pink tutus”) ). It is remarkable that transgender children understand and accept the same stereotypes as their peers. Studies show that “cross-gender” play (“boys wearing dresses”, “girls excelling as tom-boys”) is very common in pre-school children, is normal, and is temporary in most children.

Where are all these transgender children?Everywhere. Since 2007 when Childrens Hospital started its Gender Management Service as part of their Sexual Disorders and Dysfunctions Clinic,they have treated about 200 transgender children, 95% of whom came from within 150 miles of Boston.

What causes transgender identification, nature or nurture?
Both probably. No one really knows. One twin study revealed that of 23 identical same-sex twin pairs, one twin in 9 of the pairs was identified as transgender. No twin in the 21 fraternal same-sex twin pairs were transgender. The suspected genetic basis of this is completely unknown. In 1895 an article in Scientific American expressed concern that riding bicycles threatened women’s health. In 1948 only 32% of adults believed women should wear slacks in public. (1)

What is the “treatment”? (2)The Dutch taught us that the best time to change a person’s gender is before the onset of puberty (10-12 yo. in girls and 12-14 yo. in boys).

Dr. Spack and others thought that was a pretty young age for the patients (and their families) to make such a life-changing and permanent decision. Therefore, the U.S. standard of care is to delay puberty to buy some time.

At age 12 years after extensive psychometric testing of gender identification by a multi-specialty team, treatment with appropriate sex hormones that block progression of puberty of the “birth gender” is started. This puberty “blockage” is reversible and is continued for years.

At age 16 after the repeat of extensive psychometric testing of gender identification, the decision to move on to irreversible body-changing sex hormone treatment is considered. . If the decision is to NOT GO on with the change, that hormonal treatment is stopped and normal puberty appropriate to the “birth gender” occurs. If the decision is to proceed with a change, treatment with different sex hormones appropriate to the “affirmed gender” is started. The goal is to achieve the physical appearance of the “affirmed gender”. This treatment is usually very successful (“girls develop normal sized breast and have normal heights”).

After age 18 years and years of hormonal therapy, surgical reconstruction of genitalia can be considered. (Male-to-female surgery is much easier and can be successful enough to “fool a gynecologist”.)

Are there any barriers to treatment?Yes. Very expensive (about $1000 a month for several years of hormonal treatment), misunderstanding about the reversibility of early treatment, and continued classification in the DSM-V (Diagnostic and Statistical Manual of Mental Disorders) of “Gender Identification Disorder” as one of a dozen “Sexual Disorders and Dysfunctions” (which exempts the treatment from most insurance plans). Note: Homosexuality was removed in 1973 from the DSM-III as a mental health disorder as it is NOT amenable to psychiatric therapy. Neither is transgender identity. There is no evidence that people can be talked out of, or therapized away from, their transgender identity.

What if the transgender child is not treated?In the scheme of things the number of transgender children is limited. But, of the 100 patients seen by the Gender Management Service by 2012, 20% had performed self-mutilation and 10% had attempted suicide. Other studies have documented a much higher-than-average suicide rate in persons with gender identity issues.

So, gender identity can trump anatomy,
and sexual orientation can be completely unrelated to either.

This can get a bit confusing, but have no fear, it may even get harder to keep track of the players without a scorecard.
New research is focussing on “nonbinary” children. These children see themselves as in the middle of the spectrum and neither male nor female.

Refrences:
1. Scientific American, “Everybody has a stake in the new science of sex and gender”, September 2017
2. TED talk, Norman Spack, MD